PAYMENT AUTHORISATION FORM
Please either, i) print & complete the authorisation form below and post it to us;
or, ii) telephone us with your Credit/Debit Card details
Tel: +44 (0)1388 608204

For your security we advise you not to e-mail your Credit/Debit Card details to us.

Please Note: We add a 2% surcharge to all CREDIT CARD transactions.
Debit Card transactions are free of surcharge.
All transactions are in £ Sterling.

Payment of Five Gables Cottage Hire Charges
by Credit/Debit Card

Visa / Mastercard / Delta / Maestro / Solo cards only.
We are unable to accept ELECTRON cards without the cardholder being present.

Valid from ____/____Expiry Date of Card ____/____ Issue No. if applicable ____

Card Number __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Last 3 numbers on signature strip__ __ __

Amount £______________ + 2% Surcharge (Credit Card only) of £ _____:____

Total amount (including surcharge if payment by Credit Card) £________:_____

If the name & address of the Cardholder are not the same as the Hirer, please write them below:

Cardholder's Name: [as on card] ___________________________________________

Cardholder's Address ____________________________________________________________

______________________________________________________________________________

Post/Zip Code______________

I authorise you to debit my credit/debit card for the Total amount shown above.

Signature: ___________________________ Date: __________________